Journal List > Ann Occup Environ Med > v.28(1) > 1124947

Park, Park, Kim, Park, Choi, and Lim: The association between long working hours and hearing impairment in noise unexposed workers: data from the 5th Korea National Health and Nutrition Examination Survey (KNHANES 2010–2012)

Abstract

Background

This study is aimed at finding out the relationship between long working hours, one of major job stress elements, and hearing impairment in unexposed workers to occupational and environmental noise.

Methods

This study was performed on 1628 regular, full-time wage workers between the age of 25-64 who indicated in the survey of having no experience of exposure to noise, normal otoscopic findings, and not suffering from diabetes based on the data from the fifth Korea National Health and Nutrition Examination Survey (KNHANES 2010–2012). The average working hours per week was categorized into 40 h and lower group, more than 40 to 48 h group, more than 48 to 60 h group, and more than 60 h group. The groups were defined as suffering from low or high frequencies hearing impairment if the average hearing threshold for 0.5, 1, 2 kHz or 3, 4, 6 kHz in both ears exceeds 25 dB based on the pure tone audiometry. The association between average weekly working hours and hearing impairment was analyzed using logistic regression after gender stratification.

Results

The prevalences of low and high frequencies hearing impairment in male workers were 4.3 and 28.6 %, respectively, which were much higher than female’s prevalence of 2.7 and 11.1 %. For male workers, no significant association was found between average weekly working hours and low and high frequencies hearing impairment. For female workers, odds ratios (OR) of low and high frequencies hearing impairment were 4.22 (95 % confidence interval (CI) 1.09–16.27) and 4.49 (95 % CI 1.73–11.67), respectively, after controlling for several related factors, such as, age, Body Mass Index (BMI), socio-economic status, health-related behavioral, and occupational characteristics variables, in the final model in the group working more than 60 h compared to the group working 40 h and lower. In addition, a dose-response relationship was observed that ORs of low and high frequencies hearing impairment were increased according to increasing average weekly working hours.

Conclusions

The association between long working hours and hearing impairment in both low and high frequencies was significant in Korean female workers with a dose-response relationship. Therefore, the law to change the culture of long working hours should be enacted in order to protect the workers’ health and improve the quality of life in Korean workers.

Abbreviations

BMI

Body mass index

CI

Confidence interval

GR

Glucocorticoid receptor

HPA

Hypothalamic-pituitary-adrenal axis

ILO

International labor organization

KNHANES

Korea National Health and Nutrition Examination Survey

OECD

Organization for economic cooperation and development

OR

Odds ratio

SLOSH

Swedish longitudinal occupational survey of health

WHO

World Health Organization

Background

The International Labor Organization (ILO) announced the first agreement limiting daily working hours to 8 h and weekly working hours to 48 h for the manufacturing sector in 1919. Around 100 years have passed since then, and the statutory working hours have decreased gradually with many countries currently limiting it to 40 h per week [1]. However, there is a difference in the actual working hours by country with many developing countries still showing long working hours compared to developed countries due to reasons of low hourly wage, non-existence of a labor union, and insufficient labor market management capacity [2]. In the case of Korea, despite the fact that it has been industrialized as a typical country which has East Asia’s distinctive ‘long working hour culture’ [2], the characteristic of long working hours still exists, and it held the second-highest record for long working hours among the Organisation for Economic Co-operation and Development (OECD) countries in 2014 [3].
The results of previous studies suggested that long working hours have had influence in various fields. In the short term, long working hours increase fatigue through growing job demands, interference with life outside work, and shortening sleep time and cause negative health behaviors, such as, smoking and alcohol abuse [4]. These results increase the occurrence of accidents in workplace [5], mental illnesses [6], and cerebro-cardiovascular diseases [7] on a personal level and lead to social losses, such as, declining productivity [8] and frequent absences [9] in the long term.
Meanwhile, hearing impairment creates problems, such as, difficulty in formation of relationships, social isolation, and limited career choices and it has become an important social problem that causes mental illness like depression [10]. Increasing age, history of ear diseases, diabetes, and smoking are common causes of hearing impairment which lead to various problems mentioned above in the general population while the major cause is exposure to occupational noise in the working population [1113].
In addition, some studies presented the association between stress and hearing problems. In a study conducted on symphony orchestra musicians occupationally exposed to loud noise frequently, it has been observed that there is a significant correlation between stress-related symptoms and hearing problems, with most hearing problems starting off gradually after a stressful life event [14]. Meanwhile, another study analyzed the impact of stress on hearing in workers unexposed to noise. A study analyzing the Swedish Longitudinal Occupational Survey of Health (SLOSH) data in 2008 reported that increase in stress, such as, change of occupation or risk of dismissal raised the prevalence of hearing impairment or tinnitus [15]. A case-control study conducted in Germany showed that patients with sudden hearing impairment and acute tinnitus symptoms even without being exposed to loud noise had a significantly higher level of stress compared to the control group, suggesting that stress can be considered a significant risk factor in occurrence of these diseases [16]. Based on these previous studies, the idea that stress can cause or aggravate hearing impairment was proposed [17].
However, most previous studies did not differentiate hearing impairment and tinnitus or hyperacusis, based on a self-reported survey regarding hearing impairment, and not excluding well-known hearing impairment related factors. Therefore, this study is aimed at revealing the association between one of major stress elements, long working hours, and hearing impairment by using the data from the fifth Korea National Health and Nutrition Examination Survey (KNHANES) and analyzing the working hours which have not been presented as the cause of hearing impairment until now, although being one of the most important stress factors in the occupational health field [18].

Methods

Study participants

The KNHANES is a study conducted on Koreans nationwide by the Korea Centers for Disease Control and Prevention with the first survey conducted in 1998 and the sixth survey currently in progress. The data from the fifth KNHANES carried out from 2010 to 2012 was used in this study. The survey was constructed with independency and homogeneity through the introduction of the Rolling Sampling Survey in each survey year. In the fifth KNHANES, 192 sampling areas were chosen each year representing Koreans and all members of the 3800 households were surveyed, therefore, 11,400 households from a total of 576 areas surveyed in 3 years.
This study was performed on regular, full-time wage workers between the age of 25–64 among the total study participants of the fifth KNHANES. Among them, 1815 workers unexposed to noise who answered ‘no’ to ‘have experience using earphones at a noisy place’, ‘have experience being exposed to noise at workplace’, and ‘have experience being exposed to instantaneous noise’, and also have been diagnosed normal for both ears in otoscopic examination conducted by a otolaryngologist using 4 mm degree endoscope were chosen. The final study population was determined to 1628 study participants by excluding workers diagnosed with diabetes to rule out the impact of diabetes on hearing impairment [19, 20], soldiers with possible frequent exposure to firing noise, and participants with missing question entry in each variable.

Long working hours

The International Labor Organization (ILO) stated that working more than 48 h a week is considered a major job stress and that the occurrence of cerebro-cardiovascular diseases are highly associated with working hours exceeding 60 h per week [21]. Therefore, it was advised to avoid working more than 48 h per week and best not to exceed 40 h per week. Many countries have already limited the statutory working hours to 40 h per week [1], while paragraph 1 of Article 50 of the Korean Labor Standards Act of Korea also states that working hours should not exceed 40 h per week excluding recess hours [22].
Based on these standards, this study made evaluations by using the value of the response to the question ‘how many hours do you work per week on average at work place including overtime and night overtime, excluding lunch hours?’ and classifying them into group working 40 h and lower, group working more than 40 to 48 h, group working more than 48 to 60 h, and group working more than 60 h.

Hearing impairment

To evaluate the hearing level of the study participants, a pure tone audiometry at 0.5, 1, 2, 3, 4, 6 kHz was conducted on both ears through the Entomed SA 203 in a double wall audiology booth. World Health Organization (WHO) had defined normal hearing as the average result recording below 25 dB at 0.5, 1, 2, 4 kHz for the good-ear side [23], and it is widely used as the standard in judging daily life auditory abilities. However, using such definition to judge the degree of hearing impairment will rule out unilateral hearing impairment and lead to the emergence of the problem of not being able to find out the pattern of hearing impairment. To resolve this problem, some studies have defined hearing impairment with the average hearing threshold in both ears [24], and analyzed the pattern of low and high frequencies hearing impairment [25]. Based on this information, this study defines the binaural pure-tone average of both ears at 0.5, 1, 2 kHz for low frequency and the binaural pure-tone average at 3, 4, 6 kHz for high frequency. In addition, the binaural pure-tone average of both ears for low frequency or high frequency exceeding 25 dB was judged as having hearing impairment.

Other variables

In this study, some related factors that can affect hearing impairment suggested by previous studies were included. Some studies showed relatively consistent results that cerebro-cardiovascular risk factors, such as obesity and smoking, have a negative effect on hearing [26, 27]. These results were considered to be due to the fact that cochlea was vulnerable to ischemic changes [28]. In a research relating to the socio-economic status, high prevalence of hearing impairment was observed in deprived families. This finding was explained by frequent prematurity and low birth weight in the lower socio-economic status [29], and a negative tendency for the noisy environment and a favor for wearing hearing protection aids in the higher socio-economic status individuals [30]. In addition, there was a limited evidence that healthy lifestyles, such as moderate exercise and moderate alcohol consumption, can help prevent hearing loss [31, 32].
The related factors were constructed as follows to consider socio-economic status, health-related behavior characteristics, and occupational characteristics of the study participants. The age was classified into units of 10 years with Body Mass Index (BMI) of less than 18.5 kg/m2 classified as underweight, BMI of 18.5–25 kg/m2 normal weight, and BMI of over 25 kg/m2 overweight. Socio-economic status included level of educational attainment, marital status, and household income. The level of educational attainment was classified into less than high school, graduated from high school, and graduated from junior college or higher educational level. The marital status was classified into single, married and living together, and others (separated, death of spouse, divorced). The household income was classified into four classes of low, middle-low, middle-high, and high in accordance with the monthly average equivalent household income (monthly household income divided by the square root of number of household members).
Health-related behavior characteristic variables include smoking, alcohol consumption, and exercise status. Smoking was classified into non-smoker for participants who have smoked less than 100 cigarettes in their lifetime, ex-smoker for those who smoked more than 100 cigarettes in their lifetime but currently not smoking, and current smoker for those currently smoking and have smoked more than 100 cigarettes in their lifetime. Alcohol consumption was classified into non-drinker for participants who did not drink at all in the past year, light drinker for participants drinking less than twice a week or drinking less than seven glasses per occasion for male (less than five glasses for female), and high-risk drinker for those drinking more than twice a week or drinking more than seven glasses per occasion for male (more than five glasses for female). The exercise status was classified into exercise group for participants having conducted intense physical activities more than 3 days a week and over 30 min per occasion resulting in experiencing body pain or breathing heavily than usual while those not applicable to such activities were classified as non-exercise group.
Occupational characteristic variables include job type and shift work status. The job type was classified mainly into non-manual jobs for ‘manager’, ‘specialist and related business employee’, ‘office worker’, and ‘service industry employee’ and manual jobs for ‘workers skilled in agriculture and fishery’, ‘technician or related skill employee’, ‘machine operating or assembly worker’, and ‘simple labor employee’. The shift work status was classified into day work group and shift work group for participants applicable to work pattern other than day shift (evening shift, night shift, day and night regular shift, 24-hour shift, split shift, irregular shift, and others).

Statistical analyses

The fifth KNHANES is designed with all Koreans living in Korea as the target population and it is a complex sampling design data extracted after conducting the initial area-stratification and then the secondary stratification of households within the area. In this study, analysis was carried out considering weight, stratified variables, and cluster variables so that the sample represents the population and prevents biased outcomes.
To examine the general characteristics of the study population, the frequency and the average of each independent variable were presented through stratification by gender while chi-square tests were conducted to compare the distribution and t-tests were conducted to figure out significant mean difference. Taking into consideration previous study outcomes showing significant health impacts of long working hours on female workers [3335], the association between the independent variables and hearing impairment was gender-stratified and then chi-square tests were conducted, and the results were presented by classifying it into low and high frequencies hearing impairment. To find out the degree of the association between long working hours and low and high frequencies hearing impairment by gender, logistic regression was applied to calculate odds ratio (OR). In the crude model, no adjustments were made while age, BMI, and socio-economic status variables were controlled in the second model, and health-related behavior characteristic variables and occupational characteristic variables were more controlled in the final model. SPSS v.19.0 was used for the statistical analyses and the significance level was set at p < 0.05.

Results

General characteristics of the study population

The general characteristics of the study population are presented in Table 1. Among all participants, male accounted for 53.7 % and female 47.3 %. The average age was 40.3 years for male and 39.6 years for female and the average age was slightly higher in male workers without statistical significance (p = 0.174). The proportion of educational attainment level of college or higher was significantly higher in male (p = 0.003) with the proportion of manual job in male at 31.0 % and higher than that of female of 16.8 % (p < 0.001). The proportion of shift work in female was slightly higher but not statistically significant (p = 0.239). The average working hours per week in male was 49.2 h, showing significantly longer than female’s 44.5 h (p < 0.001) while the percentage of group working more than 60 h in male was significantly higher than that in female, with male accounting for 12.6 % and female 7.2 % (p < 0.001).
Table 1
General characteristics of the study population
aoem-28-55-i001
Variables Total Male Female p-value
na nb(%c) na nb(%c) na nb(%c)
Total 1628 3780449(100.0) 768 2030862(100.0) 860 1749588(100.0)
Age (years)
 Mean ± SE 40.0 ± 0.3 40.3 ± 0.4 39.6 ± 0.4 0.174
 25–34 444 1246970(33.0) 165 610588(30.1) 279 636382(36.4) 0.069
 35–44 603 1368113(36.2) 311 791293(39.0) 292 576820(33.0)
 45–54 394 858442(22.7) 193 469842(23.1) 201 388600(22.2)
 55–64 187 306924(8.1) 99 159138(7.8) 88 147786(8.4)
BMI (kg/m2)
 Underweight 72 153504(4.1) 8 20560(1.0) 64 132944(7.6) <0.001
 Normal 1092 2480000(65.6) 454 1190804(58.6) 638 1289196(73.7)
 Obese 464 1146946(30.3) 306 819498(40.4) 158 327448(18.7)
Education
  ≤ Middle school 170 362359(9.6) 58 151184(7.4) 112 211175(12.1) 0.003
 High school 564 1427402(37.8) 252 725608(35.7) 312 701795(40.1)
  ≥ College 894 1990688(52.7) 458 1154070(56.8) 436 836618(47.8)
Marital status
 Never married 254 753440(19.9) 82 335275(16.5) 172 418165(23.9) <0.001
 Married 1289 2817011(74.5) 672 1653806(81.4) 617 1163205(66.5)
 Others 85 209998(5.6) 14 41780(2.1) 71 168218(9.6)
Household income
 Low 56 162234(4.3) 19 73594(3.6) 37 88640(5.1) 0.017
 Mid-low 381 1008432(26.7) 207 621443(30.6) 174 386988(22.1)
 Mid-high 576 1368482(36.2) 271 720932(35.5) 305 647550(37.0)
 High 615 1241302(32.8) 271 614892(30.3) 344 626410(35.8)
Smoking
 Non-smoker 967 2044875(54.1) 181 478096(23.5) 786 1566780(89.6) <0.001
 Ex-smoker 267 638628(16.9) 236 570841(28.1) 31 67787(3.9)
 Current smoker 394 1096946(29.0) 351 981925(48.4) 43 115022(6.6)
Alcohol
 None 269 549452(14.5) 80 212616(10.5) 189 336836(19.3) <0.001
 Light drinker 1123 2586279(68.4) 500 1290078(63.5) 623 1296201(74.1)
 Heavy drinker 236 644718(17.1) 188 528167(26.0) 48 116551(6.7)
Exercise
 No 1335 3060829(81.0) 619 1602748(78.9) 716 1458080(83.3) 0.051
 Yes 293 719621(19.0) 149 428113(21.1) 144 291507(16.7)
Job type
 Non-manual 1278 2857188(75.6) 554 1401179(69.0) 724 1456009(83.2) <0.001
 Manual 350 923262(24.4) 214 629683(31.0) 136 293579(16.8)
Shift work
 No 1373 3172611(83.9) 646 1730392(85.2) 727 1442219(82.4) 0.239
 Yes 255 607838(16.1) 122 300469(14.8) 133 307369(17.6)
Weekly working hours
 Mean ± SE 47.0 ± 0.3 49.2 ± 0.5 44.5 ± 0.5 <0.001
  ≤ 40 673 1460816(38.6) 243 625000(30.8) 430 835816(47.8) <0.001
 40 < x ≤ 48 401 930976(24.6) 176 480684(23.7) 225 450292(25.7)
 48 < x ≤ 60 399 1007298(26.6) 248 669145(32.9) 151 338153(19.3)
  > 60 155 381360(10.1) 101 256032(12.6) 54 125328(7.2)
SE standard error
aunweighted count, bestimated population size, ccolumn and estimated percentage

Working hours by the characteristics of the study population

Average working hours per week according to the characteristics of study population are presented in Table 2. The largest percentage of the group working 40 h and lower was shown in the case of female, older age, higher educational level, high household income, non-smoker, non-drinker, non-manual job, and day work group. In contrast, the case of male, older age, lower educational level, manual job, and shift work showed the largest percentage of the group working more than 60 h. Notably, the oldest age group, 55–64 years, showed a bimodal distribution in working hours that the largest percentage was observed both in the group working 40 h and lower and more than 60 h. In addition, the proportion of current smoker and heavy drinker was the highest in the group working more than 60 h. There was no significant difference found in relation to BMI, marital status, and exercise.
Table 2
Baseline characteristics of study participants in relation to weekly working hours
aoem-28-55-i002
Variables Average working hours per week p-value
≤40 40 < x ≤ 48 48 < x ≤ 60 >60
na %b na %b na %b na %b
Sex
 Male 625000 30.8 % 480684 23.7 % 669145 32.9 % 256032 12.6 % <0.001
 Female 835816 47.8 % 450292 25.7 % 338153 19.3 % 125328 7.2 %
Age (years)
 Mean ± SE 40.6 ± 0.4 39.1 ± 0.6 39.0 ± 0.6 42.3 ± 1.0 0.003
 25–34 434679 34.9 % 352466 28.3 % 352545 28.3 % 107280 8.6 % 0.021
 35–44 532509 38.9 % 306509 22.4 % 408269 29.8 % 120827 8.8 %
 45–54 353381 41.2 % 206971 24.1 % 196742 22.9 % 101348 11.8 %
 55–64 140247 45.7 % 65030 21.2 % 49742 16.2 % 51905 16.9 %
BMI (kg/m2)
 Underweight 66465 43.3 % 28302 18.4 % 54891 35.8 % 3845 2.5 % 0.118
 Normal 984258 39.7 % 589535 23.8 % 670664 27.0 % 235542 9.5 %
 Obese 410092 35.8 % 313138 27.3 % 281742 24.6 % 141973 12.4 %
Education
  ≤ Middle school 116233 32.1 % 77087 21.3 % 106274 29.3 % 62766 17.3 % 0.008
 High school 530333 37.2 % 342979 24.0 % 375414 26.3 % 178677 12.5 %
  ≥ College 814249 40.9 % 510911 25.7 % 525610 26.4 % 139917 7.0 %
Marital status
 Never married 268863 35.7 % 216956 28.8 % 192447 25.5 % 75174 10.0 % 0.681
 Married 1104046 39.2 % 655606 23.3 % 766179 27.2 % 291180 10.3 %
 Others 87907 41.9 % 58413 27.8 % 48671 23.2 % 15007 7.1 %
Household income
 Low 51287 31.6 % 31609 19.5 % 64473 39.7 % 14865 9.2 % 0.001
 Mid-low 313868 31.1 % 231306 22.9 % 315850 31.3 % 147408 14.6 %
 Mid-high 529608 38.7 % 334116 24.4 % 365995 26.7 % 138763 10.1 %
 High 566053 45.6 % 333944 26.9 % 260980 21.0 % 80325 6.5 %
Smoking
 Non-smoker 947579 46.3 % 533403 26.1 % 411757 20.1 % 152136 7.4 % <0.001
 Ex-smoker 220452 34.5 % 144646 22.6 % 207975 32.6 % 65555 10.3 %
 Current smoker 292784 26.7 % 252927 23.1 % 387565 35.3 % 163670 14.9 %
Alcohol
 None 244192 44.4 % 143659 26.1 % 107894 19.6 % 53707 9.8 % 0.003
 Light drinker 1031733 39.9 % 634730 24.5 % 700198 27.1 % 219618 8.5 %
 Heavy drinker 184891 28.7 % 152587 23.7 % 199206 30.9 % 108035 16.8 %
Exercise
 No 1190610 38.9 % 728900 23.8 % 823902 26.9 % 317417 10.4 % 0.611
 Yes 270206 37.5 % 202076 28.1 % 183396 25.5 % 63943 8.9 %
Job type
 Non-manual 1237357 43.3 % 695717 24.3 % 695575 24.3 % 228538 8.0 % <0.001
 Manual 223459 24.2 % 235258 25.5 % 311722 33.8 % 152822 16.6 %
Shift work
 No 1248109 39.3 % 809858 25.5 % 867887 27.4 % 246757 7.8 % <0.001
 Yes 212706 35.0 % 121118 19.9 % 139411 22.9 % 134603 22.1 %
SE standard error
aestimated population size, brow and estimated percentage

Hearing impairment and its association with relevant variables

The prevalences of low and high frequencies hearing impairment for each independent variable was presented after gender-stratified analysis in Tables 3 and 4. The prevalences of low and high frequencies hearing impairment in male were 4.3 and 28.6 %, respectively, which are much higher than female’s prevalence of 2.7 and 11.1 %.
Table 3
Characteristics by hearing impairment in male subjects
aoem-28-55-i003
Variables Low frequency hearing threshold High frequency hearing threshold
Normala Impaireda Rateb p-valuec Normala Impaireda Rateb p-valuec
Total 1943952 86909 4.3 % 1450702 580160 28.6 %
Age
 25–34 601667 8921 1.5 % 0.003 536836 73752 12.1 % < 0.001
 35–44 767129 24164 3.1 % 639708 151585 19.2 %
 45–54 433876 35966 7.7 % 228438 241405 51.4 %
 55–64 141281 17857 11.2 % 45720 113418 71.3 %
BMI (kg/m2)
 Underweight 20560 0 0.0 % 0.594 14802 5759 28.0 % 0.987
 Normal 1132208 58595 4.9 % 853128 337675 28.4 %
 Obese 791184 28314 3.5 % 582771 236726 28.9 %
Education
  ≤ Middle school 138168 13016 8.6 % 0.069 76552 74632 49.4 % < 0.001
 High school 684015 41593 5.7 % 449823 275785 38.0 %
  ≥ College 1121769 32300 2.8 % 924326 229743 19.9 %
Marital status
 Never married 330788 4487 1.3 % 0.285 293642 41634 12.4 % 0.001
 Married 1571384 82422 5.0 % 1137760 516046 31.2 %
 Others 41780 0 0.0 % 19300 22480 53.8 %
Household income
 Low 72438 1156 1.6 % 0.868 41672 31921 43.4 % 0.503
 Mid-low 591940 29504 4.7 % 434735 186708 30.0 %
 Mid-high 690088 30844 4.3 % 522569 198364 27.5 %
 High 589487 25406 4.1 % 451726 163166 26.5 %
Smoking
 Non-smoker 464148 13948 2.9 % 0.391 373600 104496 21.9 % 0.085
 Ex-smoker 535904 34937 6.1 % 380557 190284 33.3 %
 Current smoker 943901 38024 3.9 % 696544 285380 29.1 %
Alcohol
 None 200508 12108 5.7 % 0.382 141176 71441 33.6 % 0.608
 Light drinker 1246716 43362 3.4 % 933381 356697 27.6 %
 Heavy drinker 496727 31440 6.0 % 376145 152022 28.8 %
Exercise
 No 1539723 63025 3.9 % 0.428 1173529 429219 26.8 % 0.081
 Yes 404229 23884 5.6 % 277173 150940 35.3 %
Occupation
 Non-manual 1356037 45141 3.2 % 0.060 1086389 314789 22.5 % < 0.001
 Manual 587915 41768 6.6 % 364312 265371 42.1 %
Shift work
 No 1656145 74247 4.3 % 0.966 1268234 462159 26.7 % 0.012
 Yes 287807 12662 4.2 % 182468 118001 39.3 %
Weekly working hours
  ≤ 40 600759 24241 3.9 % 0.740 463403 161597 25.9 % 0.226
 40 < x ≤ 48 452960 27724 5.8 % 328092 152592 31.7 %
 48 < x ≤ 60 646323 22822 3.4 % 498059 171086 25.6 %
  > 60 243910 12122 4.7 % 161147 94885 37.1 %
aestimated population size
bprevalence rate
ctested by chi-square test
Table 4
Characteristics by hearing impairment in female subjects
aoem-28-55-i004
Variables Low frequency hearing threshold High frequency hearing threshold
Normala Impaireda Rateb p-valuec Normala Impaireda Rateb p-valuec
Total 1702929 46659 2.7 % 1555827 193761 11.1 %
Age
 25–34 630799 5583 0.9 % < 0.001 631885 4497 0.7 % < 0.001
 35–44 566561 10259 1.8 % 542400 34420 6.0 %
 45–54 374768 13832 3.6 % 300648 87951 22.6 %
 55–64 130801 16985 11.5 % 80894 66892 45.3 %
BMI (kg/m2)
 Underweight 129378 3565 2.7 % 0.119 126952 5992 4.5 % 0.292
 Normal 1247967 41229 3.2 % 1134145 155051 12.0 %
 Obese 325584 1864 0.6 % 294730 32718 10.0 %
Education
  ≤ Middle school 188166 23009 10.9 % < 0.001 138642 72534 34.3 % < 0.001
 High school 686690 15105 2.2 % 616569 85226 12.1 %
  ≥ College 828073 8545 1.0 % 800616 36002 4.3 %
Marital status
 Never married 414719 3446 0.8 % 0.125 416248 1916 0.5 % < 0.001
 Married 1123927 39277 3.4 % 1002594 160611 13.8 %
 Others 164283 3936 2.3 % 136984 31234 18.6 %
Household income
 Low 86509 2131 2.4 % 0.985 76211 12429 14.0 % 0.901
 Mid-low 376350 10639 2.7 % 340629 46359 12.0 %
 Mid-high 628839 18711 2.9 % 581604 65946 10.2 %
 High 611231 15178 2.4 % 557382 69027 11.0 %
Smoking
 Non-smoker 1526154 40625 2.6 % 0.455 1399823 166956 10.7 % 0.482
 Ex-smoker 67787 0 0.0 % 61194 6593 9.7 %
 Current smoker 108988 6033 5.2 % 94810 20212 17.6 %
Alcohol
 None 320909 15928 4.7 % 0.190 283099 53737 16.0 % 0.044
 Light drinker 1269704 26496 2.0 % 1159958 136243 10.5 %
 Heavy drinker 112316 4235 3.6 % 112770 3781 3.2 %
Exercise
 No 1417873 40208 2.8 % 0.663 1293030 165051 11.3 % 0.664
 Yes 285056 6451 2.2 % 262797 28710 9.8 %
Occupation
 Non-manual 1432594 23414 1.6 % < 0.001 1348346 107663 7.4 % < 0.001
 Manual 270335 23244 7.9 % 207481 86098 29.3 %
Shift work
 No 1402762 39457 2.7 % 0.780 1301174 141045 9.8 % 0.041
 Yes 300167 7202 2.3 % 254653 52716 17.2 %
Weekly working hours
  ≤ 40 822475 13340 1.6 % 0.014 773741 62075 7.4 % < 0.001
 40 < x ≤ 48 442782 7511 1.7 % 412838 37454 8.3 %
 48 < x ≤ 60 322857 15296 4.5 % 279331 58822 17.4 %
  > 60 114816 10512 8.4 % 89917 35410 28.3 %
aestimated population size
bprevalence rate
ctested by chi-square test
The results of the analysis conducted on the prevalences of hearing impairment according to independent variables in male showed that the prevalences of low and high frequencies hearing impairment increased by age (low frequency: p = 0.003, high frequency: p < 0.001) while the prevalence of high frequency hearing impairment was particularly high for low educational attainment (p < 0.001), others (separated, death of spouse, divorced) marital status (p < 0.001), manual job (p < 0.001), and shift work (p = 0.012). The prevalences of hearing impairment by average weekly working hours showed no significant difference in both low and high frequencies (low frequency: p = 0.740, high frequency: p = 0.226).
The prevalences of hearing impairment in female in both low and high frequencies increased by age (low frequency: p < 0.001, high frequency: p < 0.001), low educational attainment (low frequency: p < 0.001, high frequency: p < 0,001), and manual job (low frequency: p < 0.001, high frequency: p < 0.001). The characteristics showing any association with hearing impairment in only high frequency were non-drinkers (p = 0.044), others (separated, death of spouse, divorced) marital status (p < 0.001), and shift work (p = 0.041). The prevalences of hearing impairment by average weekly working hours in both low and high frequencies increased significantly as the average weekly working hours increased (low frequency: p = 0.014, high frequency: p < 0.001).

The association between working hours and hearing impairment

To find out the association between average weekly working hours and hearing impairment, logistic regression was applied based on the group working 40 h and lower after gender stratification and presented in Table 5. For male workers, ORs of low and high frequencies hearing impairment with increased working hours were not consistent and statistically insignificant in the crude model with no adjustments with related factors. On the other hand, in the final model after controlling for age, BMI, socio-economic status, health-related behavior characteristics, and occupational characteristic variables, the risk of low and high frequencies hearing impairment in the group working more than 40 to 48 h, group working more than 48 to 60 h, and group working more than 60 h increased compared to the group working 40 h and lower without statistical significance.
Table 5
Odds ratios (OR) and 95 % confidence intervals (CI) for hearing impairment by gender according to weekly working hours
aoem-28-55-i005
Weekly working hours Male Female
Low frequency hearing impairment High frequency hearing impairment Low frequency hearing impairment High frequency hearing impairment
Model 1a
  ≤ 40 1.00 1.00 1.00 1.00
 40 < x ≤ 48 1.52(0.52–4.39) 1.33(0.8–2.22) 1.05(0.35–3.14) 1.13(0.61–2.09)
 48 < x ≤ 60 0.88(0.30–2.56) 0.99(0.59–1.64) 2.92(0.85–10.06) 2.62(1.34–5.15)
  > 60 1.23(0.38–4.03) 1.69(0.96–2.97) 5.64(1.65–19.34) 4.91(2.06–11.68)
Model 2b
  ≤ 40 1.00 1.00 1.00 1.00
 40 < x ≤ 48 1.83(0.61–5.45) 1.77(0.99–3.18) 1.49(0.46–4.89) 1.44(0.74–2.78)
 48 < x ≤ 60 1.12(0.40–3.13) 1.45(0.84–2.49) 3.55(0.84–14.95) 3.84(1.82–8.1)
  > 60 1.13(0.36–3.55) 1.70(0.87–3.31) 4.24(1.05–17.14) 5.12(1.85–14.18)
Model 3c
  ≤ 40 1.00 1.00 1.00 1.00
 40 < x ≤ 48 1.79(0.65–4.98) 1.71(0.95–3.08) 1.22(0.36–4.13) 1.28(0.65–2.54)
 48 < x ≤ 60 1.10(0.44–2.77) 1.34(0.77–2.33) 2.93(0.54–15.74) 3.53(1.57–7.95)
  > 60 1.22(0.31–4.86) 1.61(0.80–3.22) 4.22(1.09–16.27) 4.49(1.73–11.67)
aModel 1 : crude model
bModel 2 : adjusted with age, BMI and socioeconomic status (education, marital status and household income)
cModel 3 : Model2 + health-related behavioral characteristics (smoking, alcohol intake and exercise) and occupational characteristics (job type, shift work)
For female workers, in the crude model without controlling for any related factors, ORs of both low and high frequencies hearing impairment showed a dose-response relationship with increasing average weekly working hours. In particular, OR of low frequency hearing impairment was significantly highest in the group working more than 60 h recording 5.64 (95 % confidence interval (CI) 1.65–19.34), while OR of high frequency hearing impairment for the group working more than 48 to 60 h was 2.62 (95 % CI 1.34–5.15) and that in the group working more than 60 h was 4.91 (95 % CI 2.06–11.68). Also, in the final model after controlling for all related factors, the dose-response relationship was maintained between average weekly working hours and hearing impairment and ORs of low and high frequencies hearing impairment in the group working more than 60 h was 4.22 (95 % CI 1.09–16.27) and 4.49 (95 % CI 1.73–11.67) with statistical significance.

Discussion

This study explored the risk of hearing impairment resulting from long working hours unexposed to occupational and environmental noise in Korean full-time wage workers based on the data from the fifth KNHANES. The risk of hearing impairment in female workers increased significantly in low and high frequencies while there was no significant result in male workers. Besides, a dose-response relationship was observed between average weekly working hours and the risk of low and high frequencies hearing impairment based on the group working 40 h and lower in female workers. The risk of hearing impairment significantly increased especially when the average weekly working hours exceeded 60 h in low frequency and exceeded 48 h in high frequency.
In the previous studies, the prevalence of hearing impairment was low in female workers [11] because the male workers are considered to be exposed more to noise than female workers in a working environment [36]. However, in this study, we explored the prevalence of hearing impairment in workers unexposed to occupational and environmental noise and the results still showed a low prevalence rate in female workers (male 28.6 % vs female 11.1 % in high frequency). The hearing protection effect of estrogen has been presented as the mechanism explaining this result. A large cohort study showed that elderly women have better hearing than elderly men and the protection effect of estrogen could be confirmed through study outcomes showing increased occurrence of hearing impairment in women with Tuner’s syndrome which prevent the production of estrogen due to ovarian dysgenesis [37].
Although the prevalence of hearing impairment was low in female workers in this study, the association between long working hours and hearing impairment was significantly high in female workers. These results are consistent with the outcomes of previous studies showing that the negative impact on health of long working hours is greater for female than male workers [38]. The gender difference could be explained by the possibility that their working conditions are differ due to difference of positions and job roles, although their occupation and working hours are the same. Even if their working conditions are the same, women could be exposed to more stress because of lower aerobic capacity and muscle force, gender segregation or relatively low wages [39]. Moreover, even if female workers are exposed to the same stress level, the impacts may be different by gender. Such difference between genders is supported by the evidence showing that male released stress quickly after work whereas the stress level in female during work was maintained even after work [40], because women performed more unpaid work for family demands, such as, housework and childcare compared to men. According to the time spent in unpaid work announced by OECD in 2015, women had 1.96 times more work than men on the average in OECD member countries, but in Korea, the figure recorded 5.05 times showing the highest concentration rate of unpaid work in women among the OECD member countries [41]. Through such results, it can be suggested that the impact on health caused by chronic cumulative stress can be more negative when working long hours in both paid and unpaid works for Korean female workers.
The mechanisms of long working hours raising the risk of hearing impairment can be explained by several aspects. First suggesting mechanism is the activation of the sympathetic nervous system caused by long working hours, changing and damaging the function of the cochlear blood flow [42]. The cochlea is vulnerable to ischemic changes because blood flow is supplied solely by the labyrinthine artery without the collateral circulation [43]. The function of the cochlea can be damaged if such ischemic changes occur in the stria vascularis of the external wall which plays an important role in maintaining cochlear homeostasis [28]. Animal test results show that the cochlear perilymphatic PO2 drops an average of 40 % when the cochlear blood flow is reduced up to 35 % and a significant hearing impairment occurs [44]. Also, the spiral modular artery branching off from the labyrinthine artery which provides blood flow to the external wall of the cochlea is rich in myofibril and locates along the sympathetic nervous system. This indicates that various internal and external factors constrict the blood vessels through sympathetic nerves and may cause ischemic changes to the external wall of the cochlea [45]. Juhn et al. reported that regular epinephrine injections had an impact on the cochlear homeostasis in an animal test using chinchillas and hearing impairment got worse in proportion to the total administration period [46]. Also, Horner et al. reported that the level of temporary hearing impairment caused by noise was reduced when a guinea pig was exposed to noise after removing the superior cervical ganglion, one of the main sympathetic nerves [47]. Through these study results, it is suggested that excessive sympathetic nerve acceleration may bring about changes in the cochlear homeostasis through ischemic changes, causing hearing impairment. In addition, hearing impairment caused by such ischemic changes can get worse due to high metabolic activity of cochlear hair cells [43].
Another mechanism of long working hours causing hearing impairment can be explained through oxidative stress. Oxidative stress is an element which can create pathophysiology of hearing impairment, damage the DNA, and have a negative impact on hearing impairment by damaging the cochlear hair cells through protein and lipid degradation and increased apoptosis [48]. There is a possibility that such oxidative stress which triggers hearing impairment can also be produced by long working hours. In a study conducted on hospital workers comparing the level of oxidative stress in blood before and after long working hours, it was confirmed that the level of oxidative stress after work increased significantly with an explanation that oxidative stress increase can be caused through continuous physical activity, mental stress, and anxiety or drowsiness [49]. Based on these, oxidative stress produced by long working hours can be suggested as having an impact on hearing impairment.
On the other hand, some animal studies present the outcome that short-term stress can show a hearing protection effect based on the explanation that glucocorticoid is produced through hypothalamic-pituitary-adrenal axis (HPA axis) and the glucocorticoid receptor (GR) which becomes activated as a result of this will start working by using heat shock proteins and antioxidants as mediators [50]. In a recent study on stress, the active process of environmental adaptation in response to such stress was defined as allostasis and it was explained that allostatic load is produced during this process [51]. Although this allostatic load can protect the body temporarily and help in adaption, it has a chance of causing diseases as pathophysiological changes occur with long-term existence. Previous studies have already found that long hours of GR activation resulting from stress may bring about negative changes in the central nervous system, such as, the prefrontal cortex [52, 53] and this change in the central nervous system will disturb the central auditory processing and interpretation, causing a negative effect on hearing. Therefore, there is a limitation to prove the hearing protection effect of stress with just the studies analyzing the effects of short-term stress.
In this study, the association between long working hours and hearing impairment was observed significantly in low frequency as well as in high frequency. Considering that hearing impairment by the major causes, such as age increase and noise exposure, was mainly observed in high frequency, it can be suggested that another pathological mechanism of hearing impairment may exist which is different from the mechanism of hearing impairment resulting from age increase or noise exposure. In a previous study, authors classified presbycusis as sensory, neural, strial, and cochlear conductive types according to pathogenesis. They reported that strial type was characterized by flat loss on pure tone audiometry and associated with ischemic changes of stria vascularis supplying the cochlea [54]. Especially, because this strial capillary network exists abundantly at the base of the cochlea rather than the apex, the apex of cochlea is relatively vulnerable to ischemic changes than the base. Therefore, this distribution of blood flow results in hearing impairment caused by ischemic changes typically present not only in high frequency but also in low frequency [55]. This supports that well-known cerebro-cardiovascular risk factors, such as smoking and diabetes, may cause hearing impairment across the entire frequency [12]. Like the cerebro-cardiovascular risk factors, long working hours is also believed to bring about ischemic changes through hyperactivity of sympathetic nervous system, causing hearing impairment in low frequency as well as high frequency through a similar pathological mechanism.
Although this study presents that long working hours may cause hearing impairment, another Korean study analyzing the association between stress and hearing impairment reported that there was no significant difference in the level of stress and hearing [56]. However, the study population of this study was college students who visited the hospital for a physical examination, showing limitation in judging the effect of exposure to chronic stress in the working environment because there was the problem of the overall stress level of the study participants being low. On the other hand, a Swedish study analyzing the association among job stress, long-term stress, and hearing impairment through the SLOSH data presented that the hearing problem increased significantly with increased stress with a dose-response relationship and the result was consistent with this study [15].
As far as we know, this study is the first study to explore the association between long working hours and hearing impairment in noise unexposed workers. This study secures representativeness and credibility using the data from the fifth KNHANES, performing hearing test and interviewing by trained researchers. This study aimed to reveal the association between long working hours and hearing impairment after controlling several related factors, such as, age, BMI, socio-economic status, health-related behavioral, and occupational characteristics, excluding not only noise exposure in the working area but also the possibility of noise exposure in everyday life, such as, the use of earphones at noisy places. Nevertheless, this study had some limitations as follows. Firstly, there was the limitation of not being able to include the past work history of the study population. Secondly, information bias may exist because the study relied on the self-reported survey instead of not measuring the actual level of noise exposure. Furthermore, study participants could not recall the whole exposure history to noise in their lifetime. Therefore, there may be a possibility that the association between long working hours and hearing impairment in this study has been biased. Thirdly, this study did not include all of the factors that could lead to hearing impairment like the histories of congenital diseases, middle ear diseases and exposures to physical trauma, medication, and toxic substances because these information was not surveyed in the original dataset, KNHANES. Fourthly, this study could not confirm the causal relationship that long working hours may cause hearing impairment because this study has a cross-sectional design.
In order to overcome the limitations of this study, a cohort study can be performed on selected workers unexposed to occupational and environmental noise through not only thorough history taking of work history, past medical history, exposures to noise, physical trauma, medication, and toxic substances, but also noise measurement of the working places and other additional tests to exclude middle ear diseases.

Conclusions

The association between long working hours and hearing impairment in both low and high frequencies was significant in Korean female workers with a dose-response relationship. The findings of this study may add some evidence to the body of knowledge of the risk of long working hours, one of well-known risk factors of health. Therefore, the law to change the culture of long working hours should be enacted in order to protect the workers’ health and improve the quality of life in Korean workers.

Abbreviations

BMI

Body mass index

CI

Confidence interval

GR

Glucocorticoid receptor

HPA

Hypothalamic-pituitary-adrenal axis

ILO

International labor organization

KNHANES

Korea National Health and Nutrition Examination Survey

OECD

Organization for economic cooperation and development

OR

Odds ratio

SLOSH

Swedish longitudinal occupational survey of health

WHO

World Health Organization

Acknowledgements

There is no conflict of interest or financial support to declare.

Availability of data and material

The data of the KNHANES V is opened to the public, therefore, any researcher can be obtained after request from the website https://knhanes.cdc.go.kr/knhanes/eng/index.do.

Funding

Not applicable.

Authors’ contributions

JWP designed this study and wrote a draft of this manuscript. JSP, SK, and MP analyzed the data, interpreted the results, and gave some comments about the manuscript. HC did technical supports. SL did critical revision of this manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

This study used the open data of the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V), 2010–2012, Korea Centers for Disease Control and Prevention (KCDC). All study participants of the KNHANES V agreed to participate the survey and signed a consent. The KNHANES V has been approved by the Institutional Review Board (IRB) of the KCDC. The approval number of first year (2010) is 2010-02CON-21-C, 2011-02CON-06-C in second year (2011), and 2012-01EXP-01-2C in third year (2012).

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